Sexual satisfaction and sexual behaviors during the COVID-19 pandemic: results from the International Sexual Health And REproductive (I-SHARE) health survey in Luxembourg

Aim To identify the impact of COVID-19 measures on sexual behaviors and sexual satisfaction in Luxembourg residents. Methods We conducted a cross-sectional online survey of adults (> 18 years of age) residing in Luxembourg, while COVID-19 restrictions were in place. The survey was available from January 15 to February 12, 2021 in four languages (French, German, English and Portuguese). Survey questions focused on masturbation, cuddling, condom use, sex frequency, sexting, cybersex, watching porn, and sexual satisfaction. Results 557 volunteers completed the survey (35.5% men, 64.3% women). Sexual satisfaction and sexual problems variables were assessed on 4-point Likert scales (0 = not at all/never to 3 = very/often). Sexual problems increased during the COVID-19 measures while sexual satisfaction decreased compared to before the introduction of COVID-19 restrictions (assessed retrospectively). Factors associated with increased odds of sexual satisfaction included having a steady relationship before COVID-19 restrictions, engaging in sexting, reporting good mental health and not altering alcohol intake. Conclusions The context of the COVID-19 pandemic and the measures implemented in Luxembourg affected sexual behaviors and sexual satisfaction. Sexual and reproductive health care centers and health professionals in general should take these results into consideration when providing care. Recommendations on the importance of sexual health for general wellbeing and behaviors associated with sexual satisfaction should be offered and possibilities to experience sexuality while reducing contamination risks be discussed.


Introduction
Since the beginning of the pandemic, the majority of governments around the world began implementing measures to interrupt the spread of SARS-CoV-2. Although varying in scale, these measures impacted people's daily lives. These measures included mandatory use of masks, Open Access *Correspondence: viniciusjfischer@gmail.com 1 Research Group Self-Regulation and Health, Institute for Health and Behaviour, Department of Behavioural and Cognitive Sciences, University of Luxembourg, Esch-sur-Alzette, Luxembourg Full list of author information is available at the end of the article and restrictions in movement, transit, gatherings, and partial or full confinement [1].
In Luxembourg, after the identification of the first COVID-19 case on March 01, 2020, the government established a pandemic crisis unit and implemented a variety of measures to contain the spread of the virus, including night-time curfew, shutting down services and commerce not considered essential, and mandatory mask use in public spaces. By July 2020, Luxembourg received a score of 45 in the Oxford Stringency Index regarding the stringency of measures introduced to contain the virus (with 0 = no measure to 100 = high restrictions) [2]. In addition, as a national health policy measure, largescale testing was offered to the population [3].
Luxembourg is one of the best-performing EU countries in terms of avoiding the worst of the economic impact of the COVID-19 lockdown, in comparison to other EU countries [2]. Governmental restrictions (remote working and schooling, closure of commerce, restaurants and sport facilities, nightly curfew, prohibition of social gatherings at home, among others) altered daily living drastically, with implications for individual well-being [4]. Furthermore, fear of infection or passing the virus on to relatives or friends might elicit feelings of anxiety, depression and other responses [5]. For example, an online survey conducted in six European countries in April 2020 found a marked increase in stress, anxiety and depression since the pandemic [4]. For cohabiting couples, the lack of possibilities for meeting others, and the reduction in leisure time activities likely increased the amount of time that couples spent together. This could lead to both positive (e.g., strengthening relationships, gratitude, appreciation and tolerance [6] and negative outcomes (e.g. exacerbation of quarrels, couples' bond diminution) [7]. It is plausible for such changes to also have affected sexual behaviors and sexual satisfaction.
To date, there is limited evidence on the impact of the COVID-19 pandemic on sexual behaviors. A study from the USA found a diversification of practices but not an increase in frequency of sexual behavior [8]. There seems to have been an increase in porn watching and in uploading sexual videos from platforms in different countries [9]. Results on sexual frequency are mixed: while Li et al. [10] and Cito et al. [11] found a decrease in sex frequency among young adults in China and in Italy, respectively, Arafat et al. [12] found no change. More conclusive results on sexual frequency would be important, as the lack of sexual activity during the lockdown has been shown to be associated with an increased risk of developing anxiety and depression [13].
Considering the importance of sexual health for general health and wellbeing [14], there is a need to better understand the impact of social restrictions on individuals' wellbeing and their sexuality. To address these and other questions around the impact of COVID-19 related lockdown measures and their effect on sexual behaviors, the I-SHARE consortium was established in early 2020. This is a collaborative effort including 30 countries with the aim of investigating sexual and reproductive health during the COVID-19 pandemic around the world [15]. The present paper presents I-SHARE results from Luxembourg. Luxembourg is one of the most densely populated countries in Europe, with almost half of the population located in the capital city of Luxembourg [16,17].
Multilingualism and multiculturalism are two important facets of Luxembourg's cultural identity, with the five largest foreign communities representing 32.3% of the total population. Furthermore, the workforce is strongly based on cross-border employees, with around 185,000 employees commuting to Luxembourg daily from France, Germany and Belgium.
The present study aims to examine the impact of COVID-19 governmental measures on the perception of change regarding sexual satisfaction, sexual behaviors, substance use and mental health in a sample of volunteers residing in Luxembourg. Specifically, we investigated factors associated with sexual satisfaction during COVID-19 related restrictions imposed at the time of the present survey, including nightly curfews, mandatory facemasks use in enclosed public spaces, closed restaurants, maximum host of 2 people from other household, and closed indoor sports facilities [18].
As these measures involved several social restrictions, we hypothesized that sexual behaviors would change as a result of these lockdown measures. With respect to in-person partnered sexual activities, we expected to find solo activities and online use for sexual purposes to increase due to the restrictions put in place.

Study population, procedure and tools
We conducted an online, cross-sectional survey from January 15 to February 12, 2021. The survey was advertised on several University of Luxembourg media platforms (website, Facebook, Instagram and Twitter) and via national agencies, focused on sexual and reproductive health. The questionnaire was available in four languages: French, German, English and Portuguese.
Prior to data collection, ethics approval was obtained from the University of Luxembourg Ethics Review Panel (ERP 20-061-C I-SHARE-Lux), and participants gave consent electronically prior to participation.
Participants met the following inclusion criteria: a) aged 18 years or older, b) residing in Luxembourg and c) fluency in one of the survey languages (French, German, English, Portuguese). All individuals who met the inclusion criteria and had access to the advertisements were invited to participate. No financial compensation or incentive was offered.
The questionnaire was developed collaboratively by the I-SHARE consortium [15]. The same survey instrument was implemented in all countries. In addition, questions could be added for country-specific reasons.
The Luxembourgish versions of the instrument were translated from the English original version into French, German and Portuguese. Participants completed the questionnaire using OpenDataKit (University of Washington, USA) in 10-30 min. To complete the survey, participants did not have to respond to all questions, only items associated with skip patterns were mandatory.
Participants were asked to respond to questions concerning sexual behavior and substance use, considering the three months before COVID-19 measures were implemented (pre-COVID-19 measures) and while COVID-19 lockdown measures were in place (during-COVID-19 measures). The sexual behavior questions encompassed: masturbation, sexual intercourse with a steady and/or casual partner, sexting, cybersex and general sexual satisfaction. Sexual satisfaction was addressed with the question "how satisfied were you with your sex life?", and sexual problems with the question: "how often have you or your sexual partner experienced sexual problems?", using 4-point Likert scales (0 = not at all satisfied; 3 = very satisfied, and 0 = never; 3 = often, respectively). We also assessed potential changes in substance use frequency between pre-and during-COVID-19 measures concerning alcohol, tobacco, cannabis, cocaine, heroin, and methamphetamine. With respect to mental health, six items assessed emotional states (frustrated, confused, afraid), and cognitive and behavioral changes (obsessive compulsive hand washing, worrying about COVID-19). Response options were: no, neither agree nor disagree, yes. One question enquired about overall mental health perception (good or poor). Questions addressed the present time but also asked if the emotional state or behavior had changed since the COVID-19 measures.
We also included sociodemographic variables (age, sex, education level, number of children) and items on sexuality and relationship status (sexual orientation; general long-term partner variables, i.e. cuddling; condom use with casual and/or long-term partners during the specified time period).

Statistical Analyses
Statistical analyses were conducted using SPSS 26. All participants with valid responses were included. As not all respondents were required to answer all questions, the number of respondents for each question varied.
First, we performed frequency analysis to describe the sample characteristics and the changes on sexual behaviors during the COVID-19 restriction measures in Luxembourg. Second, we performed a McNemar test to assess changes in sexual satisfaction and sexual problems before and during COVID-19-related restrictions. Lastly, to investigate the factors associated with sexual satisfaction during COVID-19 restrictions, we used a Binary Logistic Regression Model including as predictors demographic characteristics, sexual behaviors and mental health variables. In this step, the variable "sexual satisfaction" was recoded as a binary variable (0 = not at all/not very satisfied and 1 = somewhat/very satisfied).
The majority of participants (n = 512, 92.2%) reported following the COVID-19 measures strictly or very strictly. Regarding COVID-19 testing, 472 (84.7%) of participants reported a negative COVID-19 test result. Forty-three participants (7.7%) had tested positive COVID-19 test at least once. Self-reported frequencies of sexual behaviors, sexual problems and sexual satisfaction during the pandemic restrictions are shown in Table 2. The majority of respondents reported no changes in most of their sexual behaviors compared to before the introduction of social distancing measures. For women, behaviors that changed the most were: cuddling with 28% reporting an increase and 25% a decrease, sexual activity with a steady partner with16% reporting an increase and 39.4% a decrease, and self-masturbation with almost identical percentages reporting an increase (20.3%) or decrease (20.6%). For men, smaller changes were observed. Among the sexual behaviors that changed the most were: cuddling (increase reported by 20.9%, and decrease reported by 16.4%), sexual activity with a steady partner (increase reported by 11.8%, decrease reported by 28.2%), masturbation (increase reported by 29%, decreased reported by 10.2%) and watching pornography (increase reported by 29.3%, decrease reported by 7.1%).
Participants also reported high rates of frustration because of these restrictions, as well as other negative feelings, which are summarized in Table 3.
The factors associated with increased sexual satisfaction during COVID-19-related measures were assessed with a Binary Logistic Regression Model ( Table 4). The results summarized in Table 4 show that participants who were in a steady relationship before COVID-19 restrictions had higher odds of reporting increased sexual satisfaction (OR = 2.4, 95% CI = 1.5 -3.7, p < 0.00). Regarding sexual behaviors, participants who reported an increase in exchanging sex-content messages with a partner had higher odds of reporting increased sexual satisfaction (OR = 2.9, 95% CI = 1.0 -8.3, p = 0.04). Those who reported a decrease (OR = 2.2, 95% CI = 1 -4.9, p = 0.03) or no changes (OR = 2.8, 95% CI = 1.5 -5.2, p = 0.001) in self-masturbation, had higher odds of reporting increased sexual satisfaction.
Good mental health was associated with an increase in sexual satisfaction. Participants who reported "good" general mental health had higher odds of increased sexual satisfaction than those who indicated "poor" mental health (OR = 1.9, 95% CI = 1.2 -2.9, p = 0.002). Concerning alcohol consumption, no changes in self-reported alcohol intake were associated with higher odds for increased sexual satisfaction (OR = 1.7, 95% CI = 1.0 -3.0, p = 0.03).

Discussion
The present study examined the impact of measures imposed by the Luxembourgish government to fight the COVID-19 pandemic on self-reported sexual behaviors, substance use and mental health.
We found a decrease in sex frequency during COVID-19 compared to the period before the introduction of the COVID-19 measures. The proportion of respondents reporting a decrease in sexual activities was higher in those with steady partners (35.8%) compared to those with casual partners (14.3%). This decrease was larger than the one found in a study comparing individuals from the English and Spanish populations [7], but smaller than the decrease found in a multi-country study with 30 different countries [19]. The reasons for these differences between studies are unclear. Nevertheless, any decrease in sexual activity could have overall health implications, as a decrease in sexual intercourse has been reported to be associated with an overall decline in well-being [11].  A large proportion of the present sample (46.5%) reported low sexual satisfaction. Similar findings were also found in other I-SHARE countries where, overall, 39.6% reported low sexual satisfaction [19]. This demonstrates the need for health professionals to address sexual and reproductive health issues during the COVID-19 pandemic and the importance of sexual health for general health and wellbeing.
Our data indicate that being in a relationship before the implementation of the COVID-19 measures increased the chances of sexual satisfaction during COVID-19. This is in line with the literature, which found that people in steady relationships during the COVID-19 measures were more sexually active and also more satisfied [19]. This corroborates the evidence on the association between sexual satisfaction and more frequent sexual activity [20,21]. In addition, this is in accordance with the finding that an increase in self-masturbation was associated with higher odds of increased sexual dissatisfaction. In this context, it is plausible that self-masturbation might have been used as a coping strategy for some. In the present sample, we found a 18% increase in the frequency of masturbation, which is almost twice the percentage reported by Ibarra et al. [7], but a very similar prevalence of no change in autoerotism when compared to an Italian study (61.2% in Italy, 59.9% in Luxembourg) [11].
Findings on the relationship between masturbatory behavior and sexual activity and satisfaction are inconsistent. Masturbation offers the possibility of sexual pleasure independent of a partner's availability and sexual health. For women, masturbation seems to be related to more consistent orgasms compared with partnered sex [22][23][24]. Nonetheless, weak or negative associations between solitary and partnered sexual activity or satisfaction have been found [25,26].
With regards to sexual problems, our findings show an increase in sexual problems in those in partnership (either oneself or of the partner) during the pandemic. This result is in line with other studies that have addressed this question. Since the beginning of the pandemic, an increase in sexual problems has been found in a range of populations in different countries, for instance in COVID-19 positive women [27] and in uninfected pregnant women in Turkey [28], in women in the U.S. [29] and in men and women in Egypt [30].
Our data suggest that people who increased sexting (exchange of sex-content messages such as naked/seminaked pictures, audios or videos with a partner) had higher odds of reporting sexual satisfaction. Sexting and cybersex might have acted as a tool for different sexual activities in a person or couple's sexual repertoire [31]. Our results are in line both with other studies conducted during the COVID-19 pandemic that found the use of digital means for sexual communication a way to maintain oneself sexually active [7] and with the literature on sexting and relationship satisfaction that found higher relationship satisfaction in people who engaged in sexting [32][33][34].
With respect to mental health, the ability to adapt to the new pandemic context benefitted levels of sexual satisfaction. This becomes clear when observing that respondents who reported good general mental health presented higher scores of sexual satisfaction. This is in line with the literature, that found a higher risk of developing anxiety and depression among those who were not sexually active during the lockdown [13]. Other individual and couple protective factors to maintain mental health during the pandemic included problem-solving skills, positive reappraisal, self-efficacy, intimate partnership, social integration and mindfulness [35][36][37]. Similarly, to the adaptation findings regarding mental health, participants who reported no change in alcohol consumption had higher odds of reporting sexual satisfaction. This can possibly be explained by better personal resources to adapt to the pandemic context, and not using alcohol as a coping strategy to deal with the COVID-19 measures. Alcohol consumption as a coping strategy has been identified in previous pandemic outbreaks, e.g. severe acute respiratory syndrome [38]. So far, during the COVID-19 pandemic, an increase in alcohol consumption has been reported both in the general population [39,40] and among university students [41].

Strengths and Limitations
This study has several limitations. First, the data collection was carried out 9 months after the Luxembourg COVID-19 outbreak. Taking into consideration that some questions concerned behaviors in the 3 months prior to the pandemic outbreak, a retrospective memory bias may have occurred. Second, our study was conducted online which can lead to selection bias (e.g., only people with internet access could take part). Third, our sample was recruited using a convenience approach, predominantly via social media platforms and invitations to key sexual health organizations of the country, which limits the generalizability of the study findings. To overcome such conditions, we employed a broad recruitment strategy [42], using different social media, traditional media, press release, partnering with key governmental and non-governmental institutions as well as invitations to participants of previous COVID19 studies who agreed to be contacted for further studies. Fourth, the results obtained do not offer the possibility to evaluate factors associated with changes on sexual satisfaction, but only those associated with satisfaction while COVID-19 restrictions were in place. Dependent variable: sexual satisfaction, recoded as 0 = not at all/not very satisfied and 1 = somewhat/very satisfied a Respondent assigned as "other" did not reply to all items in this regression model and therefore was not included in the analysis Despite these limitations, this study contributes to the literature on sexual behavior during COVID-19, and the results indicate the importance of continuing research to support policy and help care provision. From a research and policy perspective, longitudinal assessments of the population are needed to properly identify their health needs. On a care provision level, sexual and mental health professionals should be trained and updated to face the population's new demands with reference to sexual behaviors and satisfaction during times of crises such as infectious disease outbreaks.

Conclusions
The COVID-19 pandemic and the social distancing measures impacted sexual behaviors of the inhabitants of Luxembourg. Sexual and reproductive health care centers and other health professionals should take these results into consideration when providing care. Recommendations on the importance of sexual health for general wellbeing and behaviors associated with sexual satisfaction should be offered and possibilities to experience sexuality while reducing contamination risks be discussed.